3

The safety of fresh frozen plasma (FFP) in developed countries has improved significantly over the past two decades due to stringent donor selection criteria and improved screening tests.In certain countries, safety is further enhanced by leucodeplet ion and pathogen inactivation. The greatest concern driving the development of pathogen reduction technologies is the prevention of blood supply contamination by new pathogens or new strains of known pathogens for which no tests currently exist. Additionally the accumulation of separate measures such as bacterial screening + viral testing + NAT + gamma

irradiation increases the overall cost of blood components.Pathogen inactivation raises the safety margin by inactivating pathogens that have gone undetected during screening due to seroconversion window periods or false results (negative or positive test).Ultimately, pathogen inactivation provides a proactive approach, inactivating emerging pathogens before they enter the blood supply chain and before screening tests have been developed and implemented1.

Transfusion-transmitted infections: risk per unit transfused.

Modified from Klein et al.2

WHAT ARE THE DRIVERS OF BLOOD SAFETY?

The SAFEST & USER-FRIENDLYtechnology for effectivepathogen inactivation inSINGLE UNITS OF PLASMA

BLOOD SAFETY

4 5

THE THERAFLEX MB-Plasma PROCESS: ULTIMATE SAFETY FOR FFP TRANSFUSION

THE THERAFLEXMB-Plasma SYSTEM:

A user-friendly and effective pathogen inactivation technique

against enveloped and non-enveloped viruses for single units of plasma.

The THERAFLEX MB-Plasma kit incorporates a dockable set suitable for both whole blood and aphaeresis plasma. The process requires a simple dry set consisting of:• a Plasmaflex fi lter for leucodepletion, removal

of residual red cells, platelets and aggregates,• a Methylene Blue pill (85μg anhydrous MB chloride),• an illumination bag,• a Blueflex filter for MB and photoproduct retention,• and a storage bag.The initial plasma volume range to be connected to the THERAFLEX MB-Plasma system is 235ml-330ml.

BLOOD SAFETY

FAST• Short illumination cycle (~ 15 min.) due to optimal

wavelength (630nm) of LED sources (light-emitting diodes)

SMALL• Optimal dimensions for bench usage• 2 bags / cycle• Operated by touchscreen

SAFE• Import/export with Local Information System (LIS)

through the MacoTrace Data Management System• Full GMP-Procedure• Full IT reporting of illumination cycle

The MacoTronic B2: the newest generationof illumination device for THERAFLEX MB-Plasma

SCD

Plasma from apheresis or whole blood

Illumination Plasma storage

Plasma filtration

MethyleneBlue

removal

CELL-REDUCED PLASMA : the Plasmaflex filter removes

residual leucocytes, red cells, platelets and aggregates

Blueflex filter

235 - 330 ml

Methylene Blueaddition

6 7

THERAFLEX MB-Plasma THROUGHPUT WITH THE MACOTRONIC B2

PROCESS SPECIFICATIONS

Illumination process (loading, cycle, labeling, unloading)

Total occupation time of the illuminator 16 min 45 sec

Hands-on time 1 min 45 sec

Preparation after illumination (transfer, purge, seal off)

Total time 12 min 40 sec

Hands-on time 40 sec

Preparation before illumination (sterile connection, plasma filtration, MB dilution, purge, seal off)

Total time 15 min 30 sec

Hands-on time 4 min

TOTAL PROCESSING TIME 44 min 55 sec

TOTAL HANDS-ON TIME 6 min 25 sec

PROCESS THROUGHPUT

Design: 1 FTE* / 3 MacoTronic B2

Hourly throughput 18.25 bags/hour

Daily throughput 146 bags/day**

Annual throughput 37,960 bags/year**

* FTE = Full Time Equivalent** 8 hours a day, 260 worked days per year

This is an example of a potential process design. Tailor made solutions corresponding to individual customer requirements are offered by Macopharma.

Simple and fast procedure (3 steps)

With a total processing time (1 MacoTronic B2)

= 44’55’’ Flexibility

• Time between collection & freezing <=24h

• Immediate availability of the treated plasma

MECHANISM OF ACTIONMethylene blue is a phenothiazine-based photosensitizer with particular affinityfor guanosine-cytosine pairs.

Methylene Blue molecule

It intercalates into viral nucleic acid and subsequent illumination generates singlet oxygen leading to guanosine oxidation and destruction of the viral nucleic acid preventing viral replication.3,4

Destruction of the viral nucleic acid

Intercalation of Methylene Blue into nucleic acid

Methylene Blue pill MacoPharma (85μg / unit of plasma)

Visible light Formation of singlet oxygen1 2 3

4

BLOOD SAFETY

FOCUS ON METHYLENE BLUE

• Methylene Blue has a monograph in the European Pharmacopeia (8th edition, 2014) and the US

Pharmacopeia (USP 38-NF 33, 2015)

• Methylene Blue is in clinical use for organ staining, as disinfectant drug

and for reversal of methemoglobinemia in very high concentrations (1.000 to 10.000 times higher than used in the

THERAFLEX MB-Plasma)

Plasma quality is maintained after treatment:• No influence on complement system, inhibitors of coagulation, fibrinolysis

markers or ADAMTS13• Coagulation factors and activation are only moderately affected (Fibrinogen,

Factor V, VIII, XI) and remain within the specifications set by the Council of Europe Guidelines

• Moderate enhanced thrombin time and aPTT• Very little effect on the strength of clot formation as assessed by thrombelastometry

(Cardigan et al., Transfusion 2009)16

PARAMETER NORMAL VALUES THERAFLEX MB-PLASMA (MACOPHARMA)

Fibrinogen (F I) (Clauss) g/l 1.50 – 3.501.915, 2.116, 1.977, 2.008, 1.959, 2.410, 2.311,

2.1421, 2.2322, 2.3523, 2.3123, 2.2923

Prothrombin (FII) U/ml 0.7 -1.3 0.965, 0.989, 0.9910

Factor V U/ml 0.7 -1.30.865, 0.7912, 0.846, 0.767, 0.799, 1.0110, 1.0211

Factor VII U/ml 0.7 -1.3 0.985, 1.028, 1.019, 1.0310

Factor VIII U/ml 0.5 -1.50.745, 0.886, 0.837, 0.668, 0.629, 0.8110, 0.9011 0.7421, 0.8022, 1.0823, 0.7023, 0.6723

Factor IX U/ml 0.5 -1.5 1.155, 0.887, 0.969, 1.0010

Factor X U/ml 0.7 -1.3 1.025, 1.019, 1.0610

Factor XI U/ml 0.7 -1.3 0.765, 0.847, 0.528, 0.759, 0.8210, 0.8211

Antithrombin U/ml 0.7 -1.3 0.945, 0.967, 1.1210, 0.8711

Protein C U/ml 0.7 -1.3 0.965, 0.897, 1.1010, 0.9511

Protein S U/ml 0.7 -1.3 1.125, 0.9919, 0.7510, 0.9411

vWF cleaving protease U/ml 0.8-1.2 1.1110, 1.3119, 0.749, 0.5011

PT (sec) 11 -15 13.15

INR 0.9 -1.3 1.085, 1.010

APTT (sec) 23 -35 34.15, 408, 3410

Prothrombin Fragments F1+2 (nM/L) 0.4 -1.4 1.2205, 0.859, 1.0311

Total protein (g/l) 595

Albumin (g/l) 365

K+ (mMol/l) 3.25

PLASMA PARAMETERS OF WHOLE BLOOD-DERIVED PLASMA AFTER MB TREATMENT:

PLASMA QUALITY AFTER THERAFLEX MB-Plasma TREATMENT

8 9

QUALITY

PLASMA QUALITY MAINTAINED

The clinical indications for THERAFLEX MB-Plasma

are in most cases the same as for standard FFP .

BLOOD SAFETY

When exposed to visible light, MB is highly effective in inactivating lipid-enveloped viruses such as HIV, HBV, HCV and the newly emergent West Nile Virus, non-enveloped viruses such as Parvovirus B19 and bacteria.

INACTIVATION OF NON-ENVELOPED VIRUSES

VIRUS FAMILY REDUCTION RATE (log 10)

Had-5 Adeno ≥ 5,33

Calici Calici ≥ 3,9

SV 40 Papova ≥ 4

Parvo B 19 Parvo ≥ 5

INACTIVATION OF ENVELOPED VIRUSES

*BVDV: Model for HCV. **PRV: Model for CMV, HBV.

Efficiency on HAV and Polio: less than 1 log

A f inal virus content below the detection limit implies a depletion at least as equivalent as the initial virus content.

Plasma filtration not only decreases transfusion reactions and HLA alloimmunisation but also provides the benefit of removing cell-associated pathogens such as cytomegalovirus (CMV) and human T-cell lymphotropic viruses (HTLV) I and II.

REDUCTION OF PARASITES

PARASITE LOG10 REDUCTION DISEASE

Trypanosoma cruzi24 >4.9 to >5.8 Chagas

REDUCTION OF CELLS (INCLUDING INTRACELLULAR VIRUSES)

MEAN OF N=12 TEST SYSTEM LIMIT

OF DETECTIONSTARTING PLASMA

AFTER PLASMAFLEX FILTRATION

END PRODUCT

Leucocytes/µlPlasmatest FACS

< 1,3 rWBC/µl 20,37 < LD < LD

Red cells/ µlPlasmatest FACS

< 3 rRBC/µl 261,02 < LD < LD

Platelets/µlSysmex SF 3000

< 10.000 rPLT/µl 14250* < LD < LD

*4 out of 12 above 10.000rPLT/μl No value above the limit of detection after filtration

BACTERIA SPECIES CUMULATIVE LOG10 REDUCTION FACTOR

Escherichia coli (PEI-B-19) ≥ 4.8

Staphylococcus epidermidis (PEI-B-06) ≥ 4.9

Staphylococcus aureus (PEI-B-23) ≥ 4.8 and ≥ 5.9

Bacillus cereus (PEI-B-07) ≥ 4.9

Klebsiella pneumoniae (PEI-B-24) ≥ 4.8

Bacillus subtilis spore preparation (DSM 618) ≥ 5.0

Brevundimonas diminuta (DSM 1635) ≥ 3.7 and 5.2

REDUCTION OF TRANSFUSION-RELEVANT BACTERIA OR BACTERIAL SPORES DUE TO THE THERAFLEX MB-Plasma PROCEDURE FILTRATION STEPS

Bacterial reduction is achieved after both filtration steps (Plasma filtration with the PLAS4 filter and MB-treated plasma filtration with the Blueflex filter) in the treated plasma. The overall reduction capacity of the THERAFLEX MB-Plasma system is sufficient to prevent transfusion-transmitted bacterial infections, taking into account the concentration of bacteria normally present in contaminated therapeutic plasma25.

EFFICIENCY

SAFETY PROFILE OF THERAFLEX MB-Plasma

A final virus content below the detection limit implies a depletion at least as equivalent as the initial virus content.

10 11

THERAFLEX MB-Plasma presents a HIGH

SAFETY PROFILE EFFICACY ON:

• Enveloped and non-enveloped viruses

• Parasites such as Trypanosoma cruzi• Unknown or untested pathogens

• Cells (intracellular viruses),leucocytes,

red cells and platelets• Bacteria

BLOOD SAFETY

VIRUS FAMILY REDUCTION RATE (log 10)

HIV-1 Retro ≥ 5.45

WNV Flavi ≥ 5.78

BVDV Flavi ≥ 5.44

HCV Flavi ≥ 3.83

DENGUE 1-4 Flavi ≥ 4.46 - ≥ 5.78

Hog cholera Flavi ≥ 5.92

Duck HBV Hepadna ≥ 6

PRV Herpes ≥ 5.48

CMV Herpes ≥ 4.08

Herpes Simplex Herpes ≥ 5.50

Bovine herpes Herpes ≥ 8.11

Influenza H3N2 Orthomyxo ≥ 4.40

Influenza H1N1 Orthomyxo ≥ 5.1

IBV Corona ≥ 4.90

Semliki Forest Toga ≥ 7.00

Sindbis Toga ≥ 9.73

Chikungunya Toga ≥ 6.58

Vesicular Stomatitis

Rhabdo ≥ 4.89

BLOOD SAFETY

CLINICAL EXPERIENCE AND WORLDWIDE PRESENCE

12 13

Clinical experience of THERAFLEX MB-Plasma: Routine use in Europe, South America and Asia Pacific.

Countries:

GermanySpainGreeceItalyUnited KingdomBelgiumMalaysia

ArgentinaRussiaBelarus AustriaBrazilSingaporeArmenia

Kazakhstan TurkmenistanHong KongSaudi ArabiaPolandUkraine

Since 1992, over 7 million units of MB-FFP have been transfused in various clinical settings. Currently there is clinical experience with MB-treated plasma produced with the THERAFLEX MB-Plasma system for more than 15 years in more than 19 countries.

www.bloodsafety.macopharma.com

Lead the wayin blood SAFETYTHERAFLEX MB-Plasma

14 15

1. Allain J.P., Bianco C., Blajchman M.A., Brecher M.E., Busch M., Leiby D., Lin L., Stramer S. 2005. Protecting the blood supply from emerging pathogens: the role of pathogen inactivation. Transfus Med Rev 19: 110-126.

2. Klein H.G., Anderson D., Bernardi M.J., Cable R., Carey W., Hoch J.S., Robitaille N., Sivilotti M.L., Smaill F. 2007. Pathogen inactivation: making decisions about new technologies. Report of a consensus conference. Transfusion 47: 2338-2347.3. Wagner S.J. 2002. Virus inactivation in blood components by photoactive phenothiazine dyes. Transfus Med Rev 16: 61-66.4. Wainwright M., Mohr H., Walker W.H. 2007. Phenothiazinium derivatives for pathogen inactivation in blood products. J Photochem

Photobiol B 86: 45-58.5. Sondag-Thull D. 2004. Plasma unitaire viro-inactivé bleu de méthylène. Croix-Rouge de Belgique Service du Sang. Brussels.6. Castrillo A., Eiras A., Castro A., Adelantado M., Areal C., Cid J., Flores J., Solla E., and Garcia-Villaescusa R. 2001. A new evaluation

of methylene blue treated plasma. Transfus. Clin. Biol. 8:103s (Abstr.)7. Hornsey V.S., Drummond O., Young D., Docherty A., and Prowse C.V. 2001. A potentially improved approach to methylene blue virus

inactivation of plasma: the Maco Pharma Maco-Tronic system. Transfus. Med. 11:31-36.8. Verpoort T., Chollet S., Lebrun F., Goudaliez F., Mohr H., and Walker W.H. 2001. Elimination of Methylene Blue from photodynamically

treated virus inactivated fresh frozen plasma: the Blueflex filter. Transfus. Clin. Biol. 8:103s (Abstr.)9. Garwood M., Cardigan R.A., Drummond O., Hornsey V.S., Turner C.P., Young D., Williamson L.M., and Prowse C.V. 2003. The effect of

methylene blue photoinactivation and methylene blue removal on the quality of fresh-frozen plasma. Transfusion 43:1238-1247.10. Reichenberg S., Walker W.H., Hoburg A., and Müller N. 2006. Theraflex MB-Plasma procedure: Plasma quality after 15 month

storage and reduciton of Methylene BLue and photoproducts. Vox Sang. 91:P-386 (Abstr.)11. Gravemann U., Pohler P., Reichenberg S., Budde U., Walker W.H., Mohr H., and Müller T.H. 2005. Quality and stability of methylene

blue-treated plasma prepared under worst case conditions. Vox Sang. 89:8-27 (Abstr.)12. Aznar J.A., Bonanad S., Montoro J.M., Hurtado C., Cid A.R., Soler M.A., and De Miguel A. 2000. Influence of methylene blue

photoinactivation treatment on coagulation factors from fresh frozen plasma, cryoprecipitates and cryosupernatants. Vox Sang. 79:156-160.

13. Lambrecht B., Mohr H., Knuver-Hopf J., and Schmitt H. 1991. Photoinactivation of Viruses in Human Fresh Plasma by Phenothiazine Dyes in Combination with Visible Light. Vox Sang. 60:207-213.

14. Mohr H., Knuver-Hopf J., Lambrecht B., Scheidecker H., and Schmitt H. 1992. No evidence for neoantigens in human plasma after photochemical virus inactivation. Ann. Hematol. 65:224-228.

15. Zeiler T., Riess H., Wittmann G., Hintz G., Zimmermann R., Muller C., Heuft H.G., and Huhn D. 1994. The effect of methylene blue phototreatment on plasma proteins and in vitro coagulation capability of single-donor fresh-frozen plasma. Transfusion 34:685-689.

16. Cardigan R, Philpot K, Cookson P, Luddington R. Thrombin generation and clot formation in Methylene blue-treated plasma and cryoprecipitate. Transfusion 2009;49(4):696–703

17. Riggert J., Humpe A., Legler T.J., Wolf C., Simson G., and Kohler M. 2001. Filtration of methylene blue-photooxidized plasma: influence on coagulation and cellular contamination. Transfusion 41:82-86.

18. Seghatchian J., and Krailadsiri P. 2001. What’s happening? The quality of methylene blue treated FFP and cryo. Transfus. Apher. Sci. 25:227-231.

19. Yarranton H., Lawrie A.S., Purdy G., Mackie I.J., and Machin S.J. 2004. Comparison of von Willebrand factor antigen, von Willebrand factor-cleaving protease and protein S in blood components used for treatment of thrombotic thrombocytopenic purpura. Transfus. Med. 14:39-44.

20. Cardigan R., Allford S., and Williamson L. 2002. Levels of von Willebrand factor-cleaving protease are normal in methylene blue-treated fresh-frozen plasma. Br. J. Haematol. 117:253-254.

21. Balaguer A., Moret A., Solves P., Bonanad S., Carpio N. and Sanz M. A. 2015. «Quality of thawed plasma inactivated with methylene blue after 48-hour storage.» Transfus Apher Sci 52(1): 141-142.

22. Coene J., Devreese K., Sabot B., Feys H. B., Vandekerckhove P., Compernolle V. 2014. Paired analysis of plasma proteins and coagulant capacity after treatment with three methods of pathogen reduction. Transfusion 54(5): 1321-1331.

23. Rapaille A., Reichenberg S., Najdovski T., Cellier N., de Valensart N., Deneys V. 2014. Factor VIII and fibrinogen recovery in plasma after Theraflex methylene blue-treatment: effect of plasma source and treatment time. Blood Transfus 12(2): 226-231.

24. Gironés N., Bueno J. L., Carrión J., Fresno M., Castro E. 2006. The efficacy of photochemical treatment with methylene blue and light for the reduction of Trypanosoma cruzi in infected plasma. Vox Sanguinis 91, 285–291

25. Reichenberg S., Gravemann U., Sumian C., Seltsam A. 2015. Challenge study of the pathogen reduction capacity of the THERAFLEX MB-Plasma technology. Vox Sang. online early26. Muniz-Diaz E. and L. Puig 2014. Allergic and anaphylactic reactions to methylene-blue-treated plasma in Catalonia in the

period 2008-2013. Blood Transfus 12(4): 628-630. Politis C., L. Kavallierou, S. Hantziara, M. Parara, E. Zervou, O. Katsarou, M. Hatzitaki, P. Fountouli, A. Gioka, K. Tzioura, S. Koumarianos, M. Asariotou and C. Richardson 2014. Haemovigilance data on the use of methylene blue virally inactivated fresh frozen plasma with the Theraflex MB-Plasma System in comparison to quarantine plasma: 11 years’ experience. Transfus Med 24(5): 316-320. Larrea L, Castrillo A, Politis C, Nussbaumer W. 2014. The incidence of allergic reactions with methylene blue treated plasma. A five-year European retrospective study. Blood Transfus (Suppl.) Bost V, Odent-Malaure H, Chavarin P, Benamara H, Fabrigli P, Garraud O, 2013. A regional haemovigilance retrospective study of four types of therapeutic plasma in a ten-year survey period in France. Vox Sang. 104(4):337-341. Nussbaumer W, Mayersbach P and Schennach H. 2013. Lower rate of adverse events with methylene-blue-treaed plasma compared with quarantine stored plasma. Vox Sang. 105 (Suppl. 2), 1–132. Seghatchian J, Walker WH, Reichenberg S. 2008. Updates on pathogen inactivation of plasma using Theraflex methylene blue system. Transfus Apher Sci; 38:271–280. Politis C, Kavallierou L, Hantziara S, Katsea P, Triantaphylou V, Richardson C, Tsoutsos D, Anagnostopoulos N, Gorgolidis G, Ziroyannis P. 2007. Quality and safety of fresh frozen plasma inactivated and leucoreduced with the Theraflex methylene blue system including the Blueflex filter: 5 years’ experience. Vox Sang. 92(4):319–326.

BIBLIOGRAPHY

The THERAFLEX MB-Plasma is a CE marked medical device. It is not available for sale in the United States.

Worldwide regulatory approvals:

Germany: PEI (Paul-Ehrlich Institute)United Kingdom: NHS (National Health Service) Spain: AEMPS (Agencia Española de Medicamentos y Productos Sanitarios)Italy: Ministry of HealthSwitzerland: SwissmedicCanada: Santé CanadaRussia: Ministry of HealthMexico: Ministry of HealthCroatia: Agency for Medicinal Products and Medical DevicesUkraine: Ministry of HealthBrazil: ANVISABelarus: Ministry of HealthKazakhstan: Ministry of HealthSingapore: HSA (Health Sciences Authority)Saudi Arabia: Saudi Food & Drug Authority (SFDA)

MACOPHARMARue LorthioisF-59420 Mouvaux (France)www.bloodsafety.macopharma.com

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